Basic Information
| Provider Information | |||||||||
| NPI: | 1891753034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAXTON-HEPBURN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PRACTICE RESOURCES LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOVA | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3157135354 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 4401000H | NY | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 00354072 | 05 | NY | MEDICAID | 00577775 | 05 | NY | MEDICAID | 01293952 | 05 | NY | MEDICAID | CA0549 | 01 | NY | RAILROAD MEDICARE | OTHER |